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Unum CL-1299 Spouse Disability Claim Physician Form

Unum uses this 9-page form for the spouse disability benefit on some long term disability plans. The physician treating the disabled spouse completes the Attending Physician Statement on pages 7 and 8: diagnosis, symptoms, findings, surgery, medications and hospital stays, then cognitive impairment and which activities of daily living need hands-on or stand-by help.

Who completes it

The physician treating the claimant for the disability completes and signs the Attending Physician Statement. The employee and spouse complete the Spouse/Employee Statement, the employer completes the Employer Statement, and the claimant signs the authorization.

Submitting and payment

How to submit it
The physician faxes or mails the completed statement to Unum's Benefits Center using the contacts printed on the form, with the required attachments.
Who pays
The form lists no fee, billing code or Unum payment for the physician statement.

Good to know

  • Required attachments: office notes for at least the past two years, test results, hospital admission and discharge summaries, and consulting physician reports.
  • The ADL list covers bathing, dressing, toileting, transferring, continence and eating, with the date assistance began and whether the need is persistent or periodic.
  • Cardiac conditions are graded by American Heart Association functional class, from Class 1, no limitation, to Class 4, complete limitation.
  • The plan administrator should send the claim 4 to 6 weeks before the spouse disability elimination period ends, or earlier if possible.

Get the official form

Download the current version from the source each time; forms change without notice.

Spouse Disability Claim Form - Attending Physician's Statement

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

How does Unum define cognitive impairment on CL-1299?

The form defines it as deterioration or loss of intellectual capacity from injury, sickness, advanced age, Alzheimer's disease or similar irreversible dementia, where the patient needs another person's assistance or verbal cueing for their own protection or the protection of others. If yes, explain and attach documentation.

What diagnosis code does the Unum spouse disability statement ask for?

The primary diagnosis line on the 05/26 revision is still printed as 'ICD 9 or DSM code'. The statement also asks for reported symptoms, physical findings such as MRI, X-ray, EMG or lab results, and any secondary conditions contributing to the disability.